AIM • FINAL YEAR MBBS • GIT & HEPATOBILIARY
KMU Past Paper Practice
Topic 3 — Obstructive Jaundice, Pancreatic Malignancy & Jaundice in Special Populations
20 A-type Single Best Answer questions • KMU-style original practice
MCQ 1
Question: A 49-year-old woman reports itching, fatigue and yellow eyes. Her bilirubin is elevated and urine dipstick is positive for bilirubin, but she has no evidence of hemolysis. Which conclusion is most consistent with this urine finding?
Options:
Only unconjugated bilirubin is increased
Water-soluble conjugated bilirubin has entered the urine
Bilirubin production has stopped
The patient has isolated Gilbert syndrome
Hepatic synthetic function is necessarily normal
Correct Answer: Water-soluble conjugated bilirubin has entered the urine
Explanation: Conjugated bilirubin is water-soluble and can be excreted in urine; unconjugated bilirubin is albumin-bound and does not appear on a urine dipstick.
MCQ 2
Question: A 43-year-old woman undergoes imaging for episodic upper abdominal pain and jaundice. Ultrasonography identifies a dilated common bile duct, but the suspected stone is not visible. She is stable without fever. What is the most appropriate next diagnostic aim?
Options:
Confirm pancreatitis using colonoscopy
Assess bile flow by routine chest radiography
Exclude hemolysis by repeating bilirubin alone
Define the ductal obstruction with MRCP or endoscopic ultrasound
Arrange an immediate liver transplant assessment
Correct Answer: Define the ductal obstruction with MRCP or endoscopic ultrasound
Explanation: MRCP or endoscopic ultrasound can detect an occult duct stone and define an obstruction before deciding whether therapeutic ERCP is needed.
MCQ 3
Question: A 58-year-old patient with obstructive jaundice develops confusion and fever while awaiting investigation. Examination shows cool extremities and low blood pressure. Which consideration most immediately changes the management plan?
Options:
Likely acute cholangitis with sepsis requiring emergency care
Expected uncomplicated pruritus from cholestasis
Possible benign inherited unconjugated hyperbilirubinemia
A need for elective dietary counseling only
Likely isolated pancreatic exocrine insufficiency
Correct Answer: Likely acute cholangitis with sepsis requiring emergency care
Explanation: Fever, altered mentation and hypotension in a jaundiced patient indicate potentially severe cholangitis; resuscitation, antibiotics and urgent drainage evaluation take priority.
MCQ 4
Question: A 66-year-old man with a suspected pancreatic head tumor has jaundice and a distended, painless gallbladder. Which interpretation is the most useful?
Options:
The finding confirms a benign gallstone
It excludes disease in the distal bile duct
It proves the pancreatic lesion is resectable
It indicates acute cholecystitis without obstruction
It raises suspicion for gradual malignant distal biliary obstruction
Correct Answer: It raises suspicion for gradual malignant distal biliary obstruction
Explanation: A painless palpable gallbladder with progressive jaundice raises concern for malignant distal biliary obstruction, although the finding is not diagnostic by itself.
MCQ 5
Question: A 60-year-old man with a pancreatic head lesion is scheduled for multidisciplinary review. CT demonstrates no distant metastasis but the report does not adequately describe vascular contact. Why should this detail be clarified?
Options:
It establishes whether bilirubin is conjugated
It determines the patient’s blood group
It helps determine whether complete tumor resection is feasible
It replaces all need for clinical counseling
It distinguishes physiological from pathological neonatal jaundice
Correct Answer: It helps determine whether complete tumor resection is feasible
Explanation: Contact with major peripancreatic vessels affects resectability and is crucial for deciding whether surgery is appropriate.
MCQ 6
Question: A 72-year-old woman with malignant biliary obstruction has persistent itching that disrupts sleep. She asks why relieving the blockage matters when cancer treatment may not be curative. What is the best explanation?
Options:
Biliary drainage guarantees cancer eradication
Decompression may reduce cholestatic symptoms and complications
Drainage prevents all future metastatic spread
Stents remove the need for future follow-up
Itching indicates that the diagnosis is benign
Correct Answer: Decompression may reduce cholestatic symptoms and complications
Explanation: Restoring bile flow can relieve jaundice and pruritus and reduce obstructive complications even when the malignancy cannot be cured.
MCQ 7
Question: A 54-year-old woman has painless progressive jaundice and dark urine. Ultrasound detects both intrahepatic and extrahepatic duct dilatation. Her initial evaluation suggests obstruction, but she has no signs of infection. Which treatment principle is most appropriate?
Options:
Give antibiotics to all patients indefinitely
Treat the bilirubin number without determining its cause
Perform exploratory surgery before cross-sectional imaging
Identify the site and cause, then select appropriate drainage or definitive therapy
Reassure her that duct dilatation is physiological
Correct Answer: Identify the site and cause, then select appropriate drainage or definitive therapy
Explanation: Stable biliary obstruction requires localization and identification of the cause so stone extraction, stenting, or surgery can be selected appropriately.
MCQ 8
Question: A 63-year-old man with pancreatic cancer is discussing treatment with his daughter present. He appears uncomfortable and has not yet indicated how much information he wishes to share. Which approach best respects patient-centred care?
Options:
Explore his preferences and obtain permission before sharing details with family
Discuss prognosis only with his daughter
Avoid the diagnosis until treatment is completed
Use technical language to establish professional authority
Promise cure to improve his morale
Correct Answer: Explore his preferences and obtain permission before sharing details with family
Explanation: Respect for autonomy means establishing what the patient wants to know and whom they authorize to receive information, then communicating sensitively.
MCQ 9
Question: A baby born at 35 weeks develops jaundice on the fourth day. Another baby born at 40 weeks has the same measured bilirubin concentration at the same postnatal hour. Why might management differ?
Options:
Both infants require identical treatment because the bilirubin values match
The more premature baby cannot develop bilirubin neurotoxicity
Gestational age has no impact after the first day
The full-term infant always needs exchange transfusion first
Lower gestational age alters risk and treatment thresholds
Correct Answer: Lower gestational age alters risk and treatment thresholds
Explanation: Gestational age modifies bilirubin neurotoxicity risk, so the same bilirubin value may cross a treatment threshold in one infant but not another.
MCQ 10
Question: A 2-day-old infant with jaundice has a history of significant bruising after a difficult instrumental delivery. Bilirubin is predominantly unconjugated. Which mechanism may be contributing to the rise?
Options:
Decreased bile flow from a pancreatic tumor
Reduced hepatic blood supply from portal hypertension
Breakdown of extravasated blood increases bilirubin load
Increased excretion of conjugated bilirubin in urine
Inherited absence of extrahepatic ducts caused by delivery trauma
Correct Answer: Breakdown of extravasated blood increases bilirubin load
Explanation: Breakdown of blood within bruised tissues increases heme turnover and bilirubin production, contributing to neonatal unconjugated hyperbilirubinemia.
MCQ 11
Question: A jaundiced newborn is increasingly sleepy, has a high-pitched cry and feeds poorly. The bilirubin level is elevated. What is the most appropriate interpretation?
Options:
These findings prove uncomplicated physiological jaundice
Neurological danger signs require immediate assessment and treatment escalation
Observation at home is sufficient if jaundice started after 24 hours
The findings establish Gilbert syndrome
The symptoms are explained solely by maternal diet
Correct Answer: Neurological danger signs require immediate assessment and treatment escalation
Explanation: Lethargy, abnormal cry and poor feeding with significant jaundice may indicate acute bilirubin encephalopathy and demand urgent assessment.
MCQ 12
Question: A 4-week-old infant continues to appear jaundiced, but the parents report normal yellow stools and good weight gain. The clinician considers breast milk-associated jaundice. Which evaluation is essential before accepting a benign explanation?
Options:
Arrange pancreatic cancer staging
Use serum CA 19-9
Request adult alkaline phosphatase reference values only
Measure total and direct bilirubin to exclude conjugated jaundice
Prescribe lifelong bile acid therapy
Correct Answer: Measure total and direct bilirubin to exclude conjugated jaundice
Explanation: Persistent infant jaundice requires bilirubin fractionation to exclude conjugated hyperbilirubinemia and clinically important cholestasis.
MCQ 13
Question: A 7-week-old infant is confirmed to have extrahepatic biliary atresia. The parents ask why referral should not be postponed. Which response is most appropriate?
Options:
Early specialist intervention improves the chance of restoring bile drainage
The disease routinely resolves without treatment after infancy
Antihistamines reverse the anatomical obstruction
Phototherapy definitively repairs the affected ducts
The condition has no long-term effect on the liver
Correct Answer: Early specialist intervention improves the chance of restoring bile drainage
Explanation: Biliary atresia causes progressive obstruction and liver injury; timely specialist treatment, including consideration of a Kasai portoenterostomy, improves outcomes.
MCQ 14
Question: An 11-year-old child with recurring yellow eyes has a raised unconjugated bilirubin level and normal aminotransferases. A relative asks whether the child should undergo ERCP immediately. Which reasoning is most appropriate?
Options:
ERCP is routine for all cases of jaundice
The bilirubin pattern proves extrahepatic obstruction
A normal ALT establishes viral hepatitis
An inherited conjugation disorder necessarily causes biliary dilatation
Isolated unconjugated hyperbilirubinemia without cholestatic signs does not justify ERCP
Correct Answer: Isolated unconjugated hyperbilirubinemia without cholestatic signs does not justify ERCP
Explanation: ERCP is an invasive biliary procedure; a pattern compatible with Gilbert syndrome does not indicate obstructed bile ducts.
MCQ 15
Question: A teenager with established Gilbert syndrome reports transient jaundice during a febrile illness. Examination is otherwise reassuring, but the family is distressed. Which advice is most appropriate?
Options:
Begin immunosuppressive therapy immediately
Avoid all exercise permanently
Explain the benign fluctuating course while reassessing if symptoms or tests are atypical
Perform surgery to prevent future episodes
Warn that progressive cirrhosis is expected
Correct Answer: Explain the benign fluctuating course while reassessing if symptoms or tests are atypical
Explanation: Gilbert syndrome is benign and can fluctuate with illness, but new symptoms or atypical laboratory findings warrant reassessment rather than automatic attribution.
MCQ 16
Question: A pregnant woman at 32 weeks describes itching without a rash. Her initial bile acids and liver enzymes are within the laboratory reference range, but the itching persists. What is the most appropriate next step?
Options:
Exclude cholestasis permanently on the basis of one blood test
Reassess and repeat bile acids and liver tests if symptoms continue
Diagnose acute fatty liver from itching alone
Proceed immediately to liver transplantation
Treat as pancreatic malignancy until proven otherwise
Correct Answer: Reassess and repeat bile acids and liver tests if symptoms continue
Explanation: Pruritus can precede biochemical abnormalities in intrahepatic cholestasis of pregnancy; persistent typical symptoms warrant repeat assessment.
MCQ 17
Question: A woman with suspected intrahepatic cholestasis of pregnancy has raised bile acids but normal bilirubin. She asks whether the absence of visible jaundice rules out the diagnosis. Which answer is most accurate?
Options:
Jaundice is mandatory for diagnosis
Normal bilirubin proves a dermatological allergy
Bile acids cannot rise before bilirubin
Cholestasis of pregnancy can occur without clinically apparent jaundice
The result establishes acute fatty liver of pregnancy
Correct Answer: Cholestasis of pregnancy can occur without clinically apparent jaundice
Explanation: Pruritus and elevated serum bile acids support obstetric cholestasis even without jaundice; bilirubin may remain normal.
MCQ 18
Question: A 35-week pregnant woman presents with vomiting and malaise. She becomes drowsy; testing reveals hypoglycemia, coagulopathy and increasing creatinine. Which feature distinguishes this presentation from uncomplicated obstetric cholestasis?
Options:
Evidence of acute hepatic metabolic failure with systemic organ dysfunction
Itching that is worse at night
A normal maternal blood pressure
Pregnancy in the third trimester
The presence of a viable fetus
Correct Answer: Evidence of acute hepatic metabolic failure with systemic organ dysfunction
Explanation: Hypoglycemia, coagulopathy, encephalopathy and renal impairment are red flags for acute fatty liver of pregnancy rather than uncomplicated cholestasis.
MCQ 19
Question: A 36-week pregnant woman has jaundice, abdominal discomfort, hypertension and thrombocytopenia. Which additional result would most strongly support HELLP syndrome rather than uncomplicated cholestasis?
Options:
An isolated increase in serum bile acids
Normal urinary protein excretion
A normal peripheral blood film
A transient mild rise in unconjugated bilirubin during fasting
Evidence of hemolysis with elevated liver enzymes
Correct Answer: Evidence of hemolysis with elevated liver enzymes
Explanation: HELLP is defined by hemolysis, elevated liver enzymes and low platelets and often accompanies hypertensive pregnancy disorders.
MCQ 20
Question: A pregnant patient has been treated for acute fatty liver and has delivered after stabilization. She asks why blood tests are still being repeated. What is the best explanation?
Options:
Delivery rules out any further maternal complication
Only fetal outcomes need monitoring after birth
Liver function, coagulation, glucose and renal recovery need continued assessment
The disorder necessarily becomes chronic cirrhosis
Repeated blood tests replace all clinical assessment
Correct Answer: Liver function, coagulation, glucose and renal recovery need continued assessment
Explanation: Maternal hepatic, renal, metabolic and coagulation abnormalities may persist after delivery and require monitoring until recovery.
